Asthma: Is Your Company At Risk?

Risk ManagementBarbara Hickcox, RN, MS

Asthma CoordinatorOhio Department of Health

Risk Management Defined

• Risk = possible adverse effects arising from hazards

• Risk Management = Proactive Decision Making Process to:

1. Assess what may go wrong (or right)2. Prioritize risks3. Develop strategies4. Implement strategies5. Reevaluate

Risk Management:

• Is a continuous process• Is a shared vision • Needs to be driven by management• Is a team effort• Often requires modification of processes• May identify opportunities• Based on communication• Looks toward the future

Risk Management

• In a disciplined environment RM provides– Processes– Methods – Tools

• Is systematic

Sometime you have to change to do Risk Management

• Cultural shift – From “Fire Fighting”, “Crisis Management”

– To Proactively resolving problems before they arise

Levels of Function

Who Does Risk Management?

Everyone–Management–Risk Manager–Safety Committee–Staff

Developing a Health and Safety Committee

• Representatives from both management and labor

• Individuals with broad contact with operations areas or people

• Representation from all areas• Interested members• Balanced representation

Steps in the Risk Management Process

Identify/Evaluate

Plan Control Track Communicate

Steps One and Two

Identify/Evaluate

Identify and Evaluate OA Risk

• Form health and safety committee• Conduct medical surveillance• Perform worksite hazard evaluation

– Confirm exposure as cause of disease– Determine OA risk levels– Check for contaminant migration off-site

• Analyze the information• Evaluate the significance

Getting StartedHow much of a problem do we

have?• Perform Medical Surveillance

– Identify– Analyze

• Hazard Assessment– Identify– Analyze

Medical Surveillance

The collection, analysis and dissemination of information pertaining to individual disease occurrences and its consequences in terms of morbidity, disability and death

Goal of Medical Surveillance

• Detect workers with asthma in early phases

• Institute measures to prevent progression

Case Definition WRA

• Immunologically mediated asthma– Sensitivity

• Asthma resulting from irritants– Non-sensitivity

• Preexisting asthma– Either one

Medical Surveillance Functions

• Recognize health changes in groups • Identify hazardous working conditions• Evaluate effectiveness of exposure controls• Assure effectiveness of exposure controls• Prevent future cases

Why Do Medical Surveillance?

• It’s the right thing to do• Screening devices with acceptable validity• Improved prognosis with prompt removal• Prevention

Occupational AsthmaPrognosis

Malo ’92, Ameille ‘97, Tarlo ‘97 Gassert ’98,

• Exposure control leads to full recovery in 15 - 45%– Short time between symptoms and diagnosis– Less severe findings on FEV1 and AHR– Similar for isocyanates, red cedar, crab, aluminum– Role for medical monitoring suggested

• Economic outcomes for workers– 46% income reduced by 1/2– 25% unemployed

Medical Surveillance Methods

• Questionnaires• Spirometery• Tests of NSBH*• Immunological Tests

* Non-specific Bronchial Hyper-reactivity, NSBH, tested with Methacholine challenge most frequently.

Medical Surveillance Questionnaires

• Most widely used• No single questionnaire has been

widely adapted or validated for OA• Burge (Occup Med, 1997)

– High sensitivity– Low specificity

Occupational Asthma Screening Questionnaire

Since your last medical (or in the last 12 months for new starters)

Have you had episodes of wheeze or chest tightness? Y N

Have you taken any treatment for your chest? Y N

Have you woken from sleep with cough or chest tightness? Y N

Have you had any episodes of breathlessness? Y N

Have you had any time off work with chest illness? Y N

Have you developed chest tightness or breathlessness after exercise? Y N

Have you developed difficulty breathing? Y N

The following additional questions may be asked:

Have you had irritation or watering of the eyes? Y N

Have you had a stuffy nose? Y N

Have you had soreness of the nose, lips, or mouth? Y N

Have you had itching or irritation of the skin? Y N

Spirometry

• Not useful in random fashion

• Perform serially as part of Medical Surveillance

• Best when combined with Questionnaire

New Devices to measure FEV1

FEV1FEV1•ReproducibleReproducible•Has low coefficient of errorHas low coefficient of error•Simple to performSimple to perform

Tests of NSBH*

• Impractical for screening worker populations

• No evidence that pre-screening can predict development of OA

• For workers with high risk, use to evaluate for OA while still actively exposed at work

* Non-specific Bronchial Hyper-reactivity NSBH

Immunological Tests

• IgE - skin testing with occupational allergens

• Relevant for HMW agents• Validated using specific

inhalation testing• Sensitivity equals or approaches

100%

What Should Medical Surveillance Look Like?

• Applied to entire exposed population

• Initial questionnaire• Immunological tests, if warranted• Further study of those with +

findings• PEFR

Timing Considerations for MS

Low Molecular Weight (LMW) Sensitizers• Before or early after start of

employment

High Molecular Weight (HMW) Sensitizers• Immediately after onset of

exposure• Spread out over longer time

intervals

Personal Risk Factors

HMW• Atopy• Smoking and atopy often

synergistic• Some agents: smokers, not

atopic, at higher risk

LMW• Nonsmokers more frequently

affected

Medical Surveillance

• If medical surveillance indicates that a worker has become sensitized you should:– Remove worker from the work environment– Advise worker to seek pulmonology or

occupational medicine physician assistance– Start the risk management process again

Is Medical Therapy + Work OK?

• Many workers cannot change jobs• If possible reduce exposure to the agent• 2 small studies

– 13 patients – treated, continued work, 1 year– 20 patients – treated, continued work, 3 years

Mild to moderate patientsNo worsening of disease2 patients retired – still have asthma

Deaths from Continued Exposure

• People have died from continued exposure to the agent

• People in 20 person study– Not diagnosed until 13 + years after

symptoms started• Precautionary measures may be

appropriate

Workplace Hazard Evaluation

1. Define purpose & scope of evaluation effort2. Become familiar with workplace environment3. Perform preliminary walkthrough inspection4. Conduct occupational hygiene field survey5. Interpret results6. Summarize results

Step Three

• Plan– Design & implement risk

management strategies

Planning for Risk Reduction

• Transform risk information into decisions and actions

• Implement the actions

Steps to Planning

• Problem Solving– Brainstorming– Cause/effect analysis– Cost/benefit analysis– Goal determination– Risk information

• Action List• Timeframe planning

Use the Committee to Plan• Committee makes decisions

– From many viewpoints– Can work out the bugs before

implementing– Can work together to get by-in to the

plan– Can speak from the viewpoint of both

labor and management– Many hands make the job smaller

Corporate Committee Functions

• Develop toxic substance evaluation & control program

• Right to know education and training• Evaluation of purchasing practices• Development and implementation of medical

surveillance program• Respiratory protection programs

Site Committee Functions

• Workplace Inspections• Accident Investigation• Records Review• Chemical and Equipment Audit• Respiratory and Protective Equipment Audit• Medical Surveillance• Pre-Occupancy Review of Leased Space

Health and Safety Committee Checklist

• Adapted from NJ Guidelines• Series of questions• Primarily related to

– Policies and procedures– Management responsibility– Systems– Specific concerns

Step Four

• Control– Correct deficiencies

Control Measures

• Once you have identified hazards and assessed the risks involved

• Find a suitable method of control:– Increase Ventilation– Eliminate/Substitute Redesign Equipment or work

process– Isolate the hazard– Introduce administrative controls– Use appropriate personal protective equipment

Implementing Controls• Define responsibilities and roles:

– Management– Supervisors– Workers

• Ensure control measures are instituted– Whose job?– How often

Control• Correct for:

– Variations in plan implementation– Variations in outcomes from

implementation• May require:

– Planning– Re-analysis of data– Additions to the Action List

Inform Workers

• Inform workers about:– Controls implemented to reduce risks– How to use the controls– Need to report defects in the system

Step Five• Track

– Continue to monitor

Track to Measure Progress• Monitor both

– Risk indicators • Medical Surveillance• Workers Comp Costs• Insurance Costs• Lost Work Days

– Actions• Interventions• Education• Compliance

Monitor Effectiveness of Controls

• Make sure that in fixing one problem you have not created another

• Monitor workplace to measure workers’ exposure to sensitizers

• Encourage workers to report• Check within 2 months of implementation

Workplace Monitoring• Done when:

– there is potential or actual exposure to a sensitizer or irritant

• Done by:– Measuring individual worker exposure– Usually done by Industrial Hygienist

• If levels are too high, institute new controls

Continuous Tracking• Routine questionnaires and spirometry

– New hires– Periodically for everyone

• System is set up to repetitively evaluate the problem • Analysis of data occurs periodically• Evaluation of the system in place• May alter recommendation with experience

Step Six

• Communicate– Ensure that all parties

understand and have ability to give input

Communicate• Provide feedback and information:

– To all individuals internally, at all levels– To pertinent outside organizations and

individuals• Information may include:

– What is going to happen– Why– What has happened– Why

• Continuous

Communication Process

ProcessData Flow

OrganizationStructure

CommitteeMeetingsMethods

Tools

InternalCommunications

ExternalCommunications

The Bottom Line

Communication of sampling results to your employees is not simply an option.

…IT’S THE LAW

Assistance with Occupational Asthma Interventions

• Consultation– Get professional assistance as

needed• Environmental evaluation and control• Study design• Diagnosis and treatment of occupational

asthma

Consultation Involves:

• Sharing of information– Employers– Workers– Workplace health and safety

officers and representatives

What to Communicate

• Issues relating to:– Risk management– Information about occupational asthma– Training

• Results of Medical Surveillance – Health and safety staff– Health consultants– Maintain medical confidentiality

Information and Training• Inform all workers:

– Causes of occupational asthma– Means of minimizing exposures

• MSDS sheets• If workers will be exposed:

– Training about hazardous substance– Controls for hazardous substance– Other substances that may cause OA

Self Reporting

• Develop a procedure for reporting symptoms• Communicate the procedure• Report should be done as soon as symptoms

are noticed - Don’t Wait• Provide training for managers so people feel

comfortable reporting symptoms• Make retraining opportunities available

Case Studies

• Hazardous work places– Turkey Farm– Body Shop– Hospital– School

• Use Developing your Work Place Asthma Management Plan – Back of manual

Preparing for First Aid

• Tell workers who have asthma to bring their Rescue medications to work - e.g. Ventolin, Proventil

• Have trained first aid personnel train people in the workplace if not available on site

First Aid• Have first aid equipment on the premises

– Large Volume Spacer• Peak Flow Meter• Form to record what was done• Follow the patient’s Asthma Action Plan• Or follow the National Guidelines

decision chart

Asthma SymptomsMild to Moderate

• Cough, breathlessness, wheeze, or chest tightness.

• Waking at night due to asthma • Decreased ability to perform usual

activities

Severe• Marked wheezing and shortness of

breath• Blue-gray tinge to skin• Trouble walking or talking due to

asthma• Accessory muscle use, retractions

Instructions to Patient• Inhaled short-acting broncho-

dilator• Up to three treatments of 2-4 puffs

by MDI at 20 minute intervals or• Single nebulizer treatment• Assess symptoms after 1 hour

Good Response (Mild Episode)• No wheezing, shortness of breath,

cough, or chest tightness and • Response to broncho-dilator

sustained for 4 hours

Incomplete Response (Moderate Episode)

• Persistent wheezing, shortness of breath, cough or chest tightness

Poor Response (Severe Episode)• Marked wheezing, shortness of breath, cough or chest tightness

• Distress is severe and non-responsive

• Response to broncho-dilator lasts <2 hours

Instructions to Patients• May continue 2-4 puffs broncho-

dilator every 3-4 hours for 24-48 hours as needed

• Contact clinician within 48 hours for instructions

Instructions to Patients Take 2-4 puffs broncho-dilator every

2-4 hours for 24-48 hours as needed Contact clinician urgently (same

day) for instructions

Instructions to PatientsIMMEDIATELY• Take up to 3 treatments of 4-6 puffs

of broncho-dilator every 20 minutes as needed

• Contact clinician• Proceed to emergency department

or call ambulance at 911

Management of Asthma Episodes by the Patient

Taken from Practical Guide for the Diagnosis and Management of Asthma, National Institutes of Health, 1997, “Management of Asthma Exacerbations: Home Treatment,” P. 27.

Step One (severe attack)

• First things first– Ask the person if this is an asthma attack– Remove the person from any exposure

area if identified– Have them sit upright– Provide reassurance (Remain Calm

yourself)

Step Two• Do a Peak Flow reading if possible• Have person take puffs from their inhaler as

directed on Asthma Action Plan– Use the spacer if available– If using a spacer ask the person to take 4 breaths

from the spacer after each puff– Take one puff at a time with brief rest after each

one (30-90 seconds)

Step Three

• Wait 20 minutes– Time it on a clock– Continue to reassure the person– Encourage them to breath slowly and

deeply

Step Four

• If there is no improvement repeat Steps 2 and 3.

• If there is still no improvement call an ambulance immediately– Dial 911– Give directions to guide EMTs to you as

quickly as possible

Implementing Personal Asthma Management Plans in the Workplace

• Identify asthmatics in the workplace

• Provide information to them about:– Asthma - particularly its inflammation– Control versus Rescue medications– Spacers– Peak Flow Meters– Asthma self management plans

Asthma Management Plans

• Suggest they discuss this information with their physician and develop an asthma management plan

• If their physician is unable or unwilling to develop a plan with them, refer to physician you have identified who will work with them

What do you do with the plans?

• You have an occupational health department:– Keep on file– Set up regular checks with asthmatics to:

• Review plan• Review medications• Review inhaler technique• Review spacer technique• Review peak flows

If You Don’t Have a Health Department?

• Do the education anyway• Suggest that asthmatics have an asthma

management plan• Identify physicians who provide

outstanding asthma care• Make spacers and peak flow meters

available• Implement an emergency action plan

What kinds of activities can you do?

1.Write a letter to your manager/administration outlining major points from the class.

2.  Make a presentation to your safety committee about the impact of asthma in the workplace.

3.  Make a proposal to your safety committee for them to ID the costs related to asthma in your workplace.

4.  Produce an outline with your safety committee of what you will do to monitor asthma in the workplace.

5.  Make a proposal to administration to form a safety committee if you do not have one.

6.  Arrange for an asthma educator to teach your employees about asthma on work time.

7. Develop an emergency asthma management plan for your company.

Summary• Asthma is a highly controllable lifelong

disease• Occupational asthma affects workers in

many settings• Every employer can save money and

decrease risk by having a comprehensive asthma risk management program